Should psychiatrists protect the public?

A new risk reduction strategy, supporting criminal justice, could be effective

As conservative members of the middle classes, most psychiatrists probably support recent criminal legislation designed to improve public protection by introducing tighter controls on high risk offenders. Psychiatrists have always contributed to public protection by detaining dangerous patients. Yet proposed mental health legislation emphasising public protection has provoked an outcry.1 The government is accused of circumventing human rights legislation by concealing preventive detention in medical disguise, with establishment figures in forensic psychiatry even urging withdrawal from psychiatry's already limited participation in public protection.2^–4 The Royal College of Psychiatrists has stated unequivocally that the only rationale for psychiatric intervention is for the benefit of patients' health and public protection is secondary. 5 The rhetoric should now cool while psychiatry determines its role in an alternative public protection framework.

The debate's moral focus has largely neglected two pragmatic questions. Firstly, is the health service equipped to take the lead in public protection? Secondly, can the philosophy underpinning strategy of the Department of Health for mental health be reconciled to the public protection agenda of the Home Office?

Many concerns derive from lack of clear limits on doctors' powers and responsibilities at a time of increasing accountability and choice for consumers. The proposed Mental Health Act minimises many previous restrictions on detention.1 Diagnosis and treatability will not be barriers. Tribunals will ratify compulsory treatments, thereby balancing patients' rights but redoubling bureaucracy. Psychiatrists will still be the gatekeepers to underresourced services. Secure services for mentally ill offenders remain inadequate and inequitable, overreliant on private beds, with delays of movement in and out of high security units and unacceptable levels of psychotic illness among prisoners. Moreover, while the Department of Health's strategy clings to the euphemism of “personality disorder,” psychopathy is the prime target and no one is fooled into thinking otherwise. As this condition is intertwined with recidivist criminality, any health led strategy implies medicalisation of offending with no clear boundary between criminal justice and health services.

The root problem remains a clash of philosophies. Proposals for “dangerous and severe personality disorder”6 were initially a joint departmental effort. But the Home Office dominated subsequent developments whereas the Department of Health's priority remained the shift of treatment from the hospital to the community. Instead of fast tracking new, secure facilities, recruiting staff, and training them in risk management, reorganisation, and reaffirmation of the policy of community care remained central, with added choice and autonomy for service “users.” 7 8 Specialist teams delivering care according to a model developed in north Birmingham guided policy, irrespective of criticisms that the model is deficient in risk assessment and both public safety and patient safety.9 Psychiatrists are confused by mixed messages: on the one hand they must reduce outmoded reliance on inpatient beds and listen more to patients' demands; on the other, they must identify dangerous patients and detain them, indefinitely if necessary.

We need a new and coherent strategy for high risk individuals led by the criminal justice system, with psychiatry in a secondary, supporting role. Scotland has already developed a variant of this proposal.10 Psychopathic individuals should be imprisoned when their offences warrant it, with discretionary life sentences to address persistent risk. The problem is that judges currently use these sentences in less than 2% of eligible cases. Psychiatrists could substantially improve the advice on risk that they currently offer. But they cannot take over the courts' role of selective incapacitation of high risk offenders.

After sentencing, prison psychologists already deliver cognitive behavioural programmes to individuals posing a high risk. If the policy of the Department of Health is truly to raise the health care of prisoners to NHS equivalence, these programmes should be enhanced and secure hospitals should deliver more intensive specialised treatments. But flexibility of movement from one system to another, according to clinical need and available expertise, must be built into new legislation and working practices.

In the community, specialist forensic psychiatry services should expand to support police and probation services, which are better equipped to operate surveillance and supervision, and to set limits. For example, the Challenge project, based in a probation hostel, has piloted the support of staff by a mental health team, offering training and advice as well as treatment interventions for individual clients.11 Multiagency public protection panels led by police and probation already operate a model of regular review and community surveillance of individuals posing a high risk.12 Multiagency public protection panels should be recognised as the primary source of community referrals for future mental health assessments under new legislation. But few trusts have so far identified resources to ensure a mental health professional on more than a handful of panels.

Psychiatric interventions cannot influence offending rates at the population level as the problem goes far beyond mental health. But psychiatrists could contribute towards targeted risk reduction in subgroups of individuals identified on the basis of previous criminal behaviour. Future risk management must shift from unrealistic over reliance on mental health legislation towards a new hybrid whereby criminal legislation becomes central. Revision at this stage may be unpalatable. But we risk misplacing ultimate responsibility unto the wrong professionals who will fail.